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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal * `� <br />Boa 1750 S: P.O. Boa 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No.. 1�i +. �r Lab. No.(s) <br />Sample Date Time <br />Collected By <br />Field Custodian - •, rr A Y' <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.v�acr <br />vuv�u �suosuvo <br />fir, a <br />q3e> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />'! f <br />1. Sample Type: Air Water `~ Soil Other (specify): <br />2. Analysis — Test series requested: '?r ), �.• '41 <br />3. Fiend Data — Preservation: r" f S, ,Z <br />J /f.r'Y/ •/ I' f� /Ji a.. j _ `: /'', /� /''t �'1f <br />4. Date analysis required by (if not Holding Time): <br />S. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial ( ) and explain below. <br />COMMENTS — Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES { ) NO ( ) If NO, explain: <br />QAC Date <br />3 <br />Page 12 of 12 <br />